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6
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1
Name
Company Description
First Name
Last Name
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2
Email
example@example.com
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3
Phone Number
Area Code
Phone Number
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4
How many employees
Please provide the number of employees, fulltime, part time, along with a high level description of their duties
How many Clerical positions
Please Select
Workers Comp
General Liability
Commerical Auto
other
Workers Comp
Please Select
Workers Comp
General Liability
Commerical Auto
other
Insurance type
Home Many owners with 15% or more ownership.
Number of other employees
How many Independent contractors
Annual Payroll
Annual Premium Paid
Description of other employees, (eg . roofers)
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5
Upload your payroll journals, insurance policies, premium statements, letters from Carrier about audit
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6
Number
Estimated Savings Range
We can save or reduce errors resulting in a 20 to 30 % saving of the Annual premium!
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